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The Cirrhosis Quicknotes provide bottom-line current recommendations regarding management of compensated and decompensated cirrhosis, including guidelines for screening and management of varices and hepatocellular carcinoma (HCC) and guidelines for the management of variceal hemorrhage, spontaneous bacterial peritonitis, ascites, hepatorenal syndrome, and encephalopathy, including dosages of recommended medications and goals of therapy. They also provide guidance regarding referral for liver transplantation.
No ascites, variceal hemorrhage, encephalopathy, or jaundice
HCC surveillance (every 6 months)
Ultrasound
AFP
Varices surveillance (upper endoscopy)
In HCV cirrhosis: if liver stiffness
<20 kPa and platelet count
>150,000, could forego endoscopy (low likelihood of medium/large varices)
Repeat endoscopy in 3 years if etiology removed OR in 2 years if ongoing injury OR at the time of decompensation
Nonselective beta-blockers (propranolol or nadolol) or carvedilol
Propranolol (20-160 mg BID) or nadolol (20-160 mg QD); titrate to maximum tolerable dosage or a heart rate of 55-60 beats/min
Carvedilol, maximum 12.5 mg/day
No need to repeat endoscopy
Nonselective beta-blockers optional
If NO beta-blockers given, repeat endoscopy: in 2 years if etiology removed OR in 1 year if ongoing injury OR at the time of decompensation
Nonselective beta-blockers (propranolol, nadolol) or Carvedilol
Propranolol (20-160 mg BID) or nadolol (40-160 mg QD); titrate to maximum tolerable dosage or a heart rate of 55-60 beats/min
Or carvedilol at maximum dose of 12.5 mg/day
No need to repeat endoscopy
OR
Endoscopic variceal ligation (choice depends on patient characteristics and preferences, local resources)
Ligate every 1-2 weeks until variceal obliteration
First surveillance endoscopy 1-3 months after obliteration, then every 6-12 months indefinitely
II. Management of Decompensated Cirrhosis
Patient has developed ascites, variceal hemorrhage, or encephalopathy
HCC surveillance (every 6 months)
Ultrasound
AFP
Varices surveillance (upper endoscopy) in a patient with decompensated cirrhosis and NO prior variceal hemorrhage
Repeat endoscopy every year
Nonselective beta-blockers (propranolol or nadolol) but not carvedilol
Propranolol (20-160 mg BID) or nadolol (20-160 mg QD)
In patients with ascites cap dose to 80 mg (BID for propranolol, QD for nadolol)
Titrate to maximum tolerable dosage or a heart rate of 55-60 beats/min
No need to repeat endoscopy
OR
Endoscopic variceal ligation
Ligate every 1-2 weeks until variceal obliteration
First surveillance endoscopy 1-3 months after obliteration, then every 6-12 months
Nonselective beta-blockers optional, doses as above
If no beta-blockers given, repeat endoscopy in 1 year
Nonselective beta-blockers (propranolol, nadolol) but not carvedilol
Propranolol (20-160 mg BID) or nadolol (20-160 mg QD)
In patients with ascites cap dose to 80 mg (BID for propranolol, QD for nadolol)
Titrate to maximum tolerable dosage or a heart rate of 55-60 beats/minute
No need to repeat endoscopy
OR
Endoscopic variceal ligation
Ligate every 1-2 weeks until variceal obliteration
First surveillance endoscopy 1-3 months after obliteration, then every 6-12 months
Variceal hemorrhage (if no history, follow guidelines for varices surveillance in compensated cirrhosis)
Any of the following findings on upper endoscopy performed within 12 hours from admission:
Active bleeding from a varix
Stigmata of variceal hemorrhage (white nipple sign)
Presence of gastroesophageal varices without another source of hemorrhage
Establish Child-Pugh score on admission
Cautious transfusion of fluids and PRBC with a goal hemoglobin of ~7-8 g/dL
Antibiotic prophylaxis (3-7 days) with:
Ceftriaxone 1 g/day (IV)
Pharmacologic therapy initiated as soon as diagnosis is suspected
Octreotide 50 mcg IV bolus followed by continuous infusion 50 mcg/hour (3-5 days)
Endoscopy within 12 hours of admission with ligation performed if variceal source is confirmed
In patients with CPS of 10-13, placement of TIPS must be considered within 24-48 hours of endoscopy (early TIPS)
Considered in patients with bleeding esophageal varices who are not candidates for early TIPS and who have failed pharmacologic + endoscopic therapy or in patients with bleeding gastric fundal varices who have failed one endoscopic therapy (cyanoacrylate)
Nonselective beta-blockers (propranolol, nadolol) but not carvedilol
Propranolol (20-160 mg BID) or nadolol (20-160 mg QD)
In patients with ascites cap dose to 80 mg (BID for propranolol, QD for nadolol)
Titrate to maximum tolerable dosage or a heart rate of 55-60 beats/min
AND
Endoscopic variceal ligation
Ligate every1-2 weeks until variceal obliteration
First surveillance endoscopy 1-3 months after obliteration, then every 6-12 months
TIPS if patient rebleeds on combined NSBB + ligation
Consider TIPS if patient bled while on NSBB or in patients who cannot tolerate NSBB (ligation alone is suboptimal tx)
Once TIPS is successfully placed, there is no need for NSBB or ligation
Spontaneous bacterial peritonitis (SBP)
Consider SBP and perform diagnostic paracentesis if:
Symptoms/signs (abdominal pain, fever, chills)
Patient is in ER or admitted
Worsening renal function or encephalopathy
SBP present if ascites PMN count
>250 cells/
µL (if fluid macroscopically bloody, subtract 1 PMN per 250 RBC/
µL)
Avoid large-volume paracenteses during active infection
Intravenous albumin (1 g/kg of body weight) if BUN
>30 mg/dL, creatinine
>1 mg/dL, bilirubin
>4 mg/dL; repeat at day 3 if renal dysfunction persists
Avoid aminoglycosides
Cefotaxime 2 g IV every 12 hours OR
Ceftriaxone 2 g every 24 hours
Ceftazidime 2 g every 8 hours
Broader-spectrum antibiotics:
Vancomycin + Zosyn or
Meropenem + daptomycin
Continue therapy for 7 days
Repeat diagnostic paracentesis at day 2:
If ascites PMN count decreases by at least 25% at day 2, IV therapy can be narrowed (if started on broad spectrum AB and organism susceptible) to complete 7 days of therapy
If ascites PMN has not decreased or increases, image the abdomen (at least flat film to detect free air), check culture results and consider broadening antibiotic spectrum
Oral ciprofloxacin 500 mg QD OR
Oral levofloxacin 250 mg QD
TMP-SMX 1 double-strength tablet PO QD (Patients who develop quinolone-resistant organisms may also have resistance to TMP-SMX)
Prophylaxis should be continued until the disappearance of ascites, time of transplantation, or death
Ascites
Treat ascites once other complications have been treated
Avoid NSAIDs
1-2 g/day
Liberalize if restriction results in poor food intake
Spironolactone based:
Spironolactone alone (start at 50-100 mg QD, single morning dose) OR
Spironolactone (50-100 mg QD) + furosemide (start at 20-40 mg QD, single morning dose)
Use as initial therapy only in patients with tense ascites; give IV albumin (6-8 g/L of ascites removed)
Adjustment of diuretic dosage should be performed every 4-7 days
Patient should be weighed at least weekly and BUN, creatinine, and electrolytes measured every 1-2 weeks while adjusting dosage
Double dosage of diuretics if:
Weight loss
<2 kg (4 lb) a week
AND
BUN, creatinine, and electrolytes OK
Halve dosage of diuretics or discontinue if:
Weight loss
≥0.5 kg (1 lb)/ day
OR
Abnormalities in BUN, creatinine, or electrolytes
Maximum diuretic dosage is spironolactone (400 mg QD) and furosemide (160 mg QD)
Ascites that is not eliminated even with maximum diuretic therapy
Ascites that is not eliminated because maximum dosages of diuretics cannot be attained given the development of diuretic-induced complications
Total paracentesis + IV albumin (6-8 g/L of ascites removed)
If
<5 L of ascites is removed, a synthetic plasma volume expander may be used instead of albumin
Continue with salt restriction and diuretic therapy as tolerated
TIPS in patients with MELD
<15 (think of it sooner rather than later); once TIPS is successfully placed, NSBB for prevention of variceal hemorrhage can be discontinued
Peritoneovenous shunt for patients who are not TIPS or transplant candidates
Hepatorenal syndrome (HRS)
Diagnosis of AKI: increase in serum creatinine by
≥ 0.3 mg/dL or
≥1.5 X from baseline
Main differential is between prerenal azotemia (most common), ATN and HRS (least common)
PRA and HRS are prerenal (functional) forms of AKI and should be suspected with FeNa
<0.5% (
<0.1% suggests HRS), evidence of volume depletion (overdiuresis, diarrhea, GI bleed), factors that will worsen vasodilatation (infection, vasodilators) or use of NSAIDs
ATN is an intrarenal (structural) from of AKI and should be suspected with FeNA
>0.5%, if there is clinical evidence of severe hypoperfusion (shock), history of nephrotoxins or contrast dye, casts in urine, albuminuria
>100 mg/dL (in the absence of CKD)
Panculture, diagnostic paracentesis, start antibiotics if strong suspicion of infection (SIRS)
IV albumin 25-50 g BID if creatinine increases despite general measures outlined above
If creatinine continues to increase despite all above measures and albumin infusion and, after excluding ATN or other structural causes of AKI, start specific therapy for HRS
A patient with HRS typically has ascites (refractory), hyponatremia, low MAP and a FeNa
<0.1%
Vasoconstrictors
Octreotide (100-200 mcg SC TID) PLUS Midodrine (7.5-12.5 mg PO TID)
Norepinephrine (0.02 to 0.4 mcg/kg/min)
Terlipressin (0.5-2.0 mg IV every 4-6 hours)
Goal to increase MAP by 10 to 15 mmHg
AND
IV albumin (50-100 g IV QD)
Both for at least 7 days
Sequence of therapy
In the absence of terlipressin (preferred):
Start octreotide+midodrine on floor but advance doses quickly based on effect on MAP, creatinine/urine output
If no effect in any of these parameters at day 3 of therapy with octreotide/midodrine
→ transfer to ICU for norepinephrine infusion
Do not assume that HE is the result of noncompliance to lactulose before ruling out precipitants
Lactulose enemas (300 cc in 1 liter of water) in patients who are unable to take it PO
Lactulose 25 mL PO every 1-2 hours until at least two soft or loose BM are produced and then adjust to 2-3 BM/day
Lactulose can be discontinued once precipitating factor has resolved
In an otherwise compensated patient in whom there is no precipitant, look for a spontaneous splenorenal shunt that could then be embolized
No long-term protein restriction
Protein from dairy or vegetable sources is preferable to animal protein
Avoid sedatives and tranquilizers
Avoid constipation
Lactulose dosage that produces 2-3 soft, formed bowel movements per day, starting at 15-30 cc PO BID
Rifaximin 550 mg PO BID in patients who cannot tolerate lactulose
Rifaximin + lactulose in patients with recurrent or persistent HE
In patients with TIPS and recurrent HE, consider TIPS reduction; if TIPS is reduced and patient needs prophylaxis for variceal hemorrhage, NSBB should be restarted
In patients without TIPS and recurrent HE, look for a spontaneous splenorenal shunt that could be embolized
and the
2009 recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program on the Management and Treatment of Patients with Cirrhosis and Portal Hypertension.
